{"paper_id":"a3d6c629-6bf9-471c-bc03-eadc1e43a7a0","body_text":"Dynamic magnetic resonance defecography (MRD) is widely recognized as a key imaging modality for the comprehensive evaluation of pelvic floor disorders (PFD), which are highly prevalent among women and represent a major public health concern [ 1 ]. The burden of PFD is expected to rise further due to demographic aging and the growing prevalence of risk factors such as obesity, multiparity, and prior pelvic surgery.\nPFD-related symptoms may arise from structural pelvic floor abnormalities, functional disorders such as dyssynergic defecation (paradoxical contraction or inadequate pelvic floor relaxation during evacuation), or a combination of both within the same patient [ 2 ]. Accurate clinical, radiological, and physiological assessment is therefore essential to appropriately phenotype patients and guide management.\nIn this context, MRD provides multiplanar, high–soft tissue–contrast, dynamic assessment of pelvic anatomy and function without exposure to ionizing radiation, making it particularly suited for the evaluation of functional pelvic floor abnormalities [ 3 ,  4 ]. MRD has demonstrated value in the evaluation of posterior compartment disorders—such as rectocele, enterocele, sigmoidocele, and rectal intussusception—as well as in complex, multicompartmental PFD, where clinical examination alone is frequently insufficient or misleading [ 5 ,  6 ].\nSeveral studies have shown that clinical examination may underestimate, misclassify or incompletely characterize PFD, with potential consequences on treatment selection and surgical outcomes [ 7 ,  8 ]. In this setting, MRD has been shown not only to improve diagnostic accuracy but also to influence clinical decision-making, including surgical planning, particularly in patients with posterior compartment prolapse or obstructed defecation [ 8 ]. Consequently, MRD is increasingly incorporated into multidisciplinary diagnostic pathways involving radiologists, colorectal surgeons, gynecologists, urologists, and gastroenterologists.\nDespite its established diagnostic value, MRD reporting remains highly heterogeneous across institutions and operators. International multisociety efforts have recently proposed standardized MR defecography lexicons and reporting templates [ 9 ]. However, these initiatives were not developed through a national, multidisciplinary Delphi process aimed at defining both minimum referral information and a feasible core reporting dataset tailored for routine implementation across heterogeneous centers. As a result, reporting practices still vary in structure, terminology, choice of reference lines, inclusion of dynamic phases, and emphasis on clinically relevant findings. This heterogeneity hampers effective communication between radiologists and referring clinicians, reduces interobserver reproducibility, and limits the comparability of data across centers, thereby undermining both patient management and multicenter research efforts [ 8 ,  10 – 12 ].\nStructured reporting has been widely adopted in multiple areas of radiology as a tool to improve clarity, completeness, and consistency of radiologic communication, while supporting multidisciplinary collaboration and data standardization [ 13 – 15 ]. In pelvic floor imaging, however, no nationally shared, multidisciplinary consensus exists regarding what information should be systematically included in MRD referrals and reports, nor how these findings should be presented in a clinically oriented and reproducible manner. Importantly, MRD is not a purely technical radiological examination but a clinically driven, question-oriented investigation, whose diagnostic value depends heavily on the quality of the referral information and on the report’s ability to address specific clinical concerns. This necessitates a shared language and agreed-upon priorities between imaging specialists and referring clinicians.\nTo address this unmet need, we conducted a multidisciplinary Delphi consensus involving Italian experts with established experience in PFD. The objectives were to define, through structured expert consensus, (1) the minimum clinical information required when requesting MRD, and (2) a core set of technical and anatomical-functional items that should be consistently included in MRD reports to improve clarity, reproducibility, and clinical utility. The goal of this work is to provide a consensus-based, structured template for MRD reports that can facilitate interdisciplinary communication and lay the groundwork for future multicenter validation studies.  Summary Statement  This modified Delphi consensus developed the first nationally shared, multispecialty template for referral and reporting in magnetic resonance defecography, aiming to improve clarity, standardization, and interdisciplinary communication in the evaluation of pelvic floor disorders.\n\nThis study was designed as a methodological, consensus-based investigation using the Delphi technique [ 16 ]. This modified Delphi method is a structured process aimed at achieving agreement among experts through iterative rounds of anonymous rating, feedback, and refinement and is particularly suited for areas where empirical evidence is heterogeneous or where standardization is lacking. This study did not involve human participants, patient data, or imaging review. According to institutional and national regulations, ethics committee approval and informed consent were not required.\nThe Delphi process involved two sequential expert panels.\nAn initial steering panel of five opinion leaders in PFD convened to define the scope and draft preliminary statements. Panel members were selected based on: (1) documented clinical experience in PFD for at least 5 years; (2) active involvement in MR defecography interpretation or referral; and (3) peer-reviewed publications in pelvic floor imaging or management.\nThis steering panel comprised three colorectal surgeons (E.B., S.C., P.T.) and two radiologists (M.F., V.P.).\nSubsequently, a second multidisciplinary panel of 20 Italian experts was assembled using purposive sampling to ensure balanced representation of all specialties involved in pelvic floor care. The final panel included 8 radiologists, 4 gynecologists, 3 colorectal surgeons, 2 urologists, 1 gastroenterologist, 1 physiatrist, and 1 methodologist. All panelists had documented expertise through clinical practice, scientific publications, and leadership roles in pelvic floor units.\nPrior to the Delphi rounds, the steering panel performed a focused narrative review of the English-language literature using PubMed, with the search terms  “MR defecography”  AND  “pelvic floor dysfunction” . This aimed to summarize current evidence regarding MRD indications, technical execution, measurement systems, reporting practices, and clinical impact.\nBased on the literature review and expert discussion, two groups of statements were developed: Statements addressing minimum clinical information required for MRD referral. Statements addressing technical, anatomical, and functional items to be included in a structured MRD report.\nStatements addressing minimum clinical information required for MRD referral.\nStatements addressing technical, anatomical, and functional items to be included in a structured MRD report.\nAll statements were reviewed and refined with methodological support from an experienced methodologist (M.R.) to ensure clarity, neutrality, and consistency with Delphi methodology.\nThe consensus process consisted of three iterative Delphi rounds conducted electronically (Google Forms). Statements were rated using a four-point Likert scale:  strongly agree ,  partially agree ,  partially disagree ,  strongly disagree  (Fig.  1 ). Consensus was predefined as ≥75% of respondents selecting  strongly agree  or  partially agree . Following each Delphi round, statements that failed to achieve the predefined consensus threshold were systematically reviewed by the five-member steering committee. Revisions were informed by both the quantitative voting results and the anonymized qualitative comments provided by panelists. Proposed modifications were aimed at improving clarity, reducing ambiguity, and addressing concerns raised during the evaluation process. The revised statements were subsequently discussed during plenary meetings and finalized by the steering committee before redistribution to the entire expert panel for anonymous reassessment in the subsequent round. Although discussion was permitted between rounds, all consensus decisions were ultimately based on anonymous voting by the full panel, consistent with the principles of a modified Delphi methodology. Fig. 1 Delphi panel composition and workflow. MRD: magnetic resonance defecography\nDelphi panel composition and workflow. MRD: magnetic resonance defecography\nThe Delphi consensus occurred in two phases aimed to produce two complementary tools: Phase I: The expert panel addressed the lack of standardization in MRD referral practices, which contributes to heterogeneity in acquisition protocols and challenges in image interpretation. A minimum referral information dataset to standardize clinical information provided to radiologists when requesting MRD was developed. Phase II: A standardized structured reporting template for MRD was developed, defining a core dataset of technical and anatomical-functional elements to be systematically reported.\nPhase I: The expert panel addressed the lack of standardization in MRD referral practices, which contributes to heterogeneity in acquisition protocols and challenges in image interpretation. A minimum referral information dataset to standardize clinical information provided to radiologists when requesting MRD was developed.\nPhase II: A standardized structured reporting template for MRD was developed, defining a core dataset of technical and anatomical-functional elements to be systematically reported.\n\nAn initial draft comprising 11 statements was developed and refined through three iterative Delphi rounds. Anonymous voting was complemented by plenary e-meetings to discuss and resolve borderline items.\nConsensus was achieved for all 11 statements. This led to the development of a minimum referral information dataset, which was unanimously endorsed by the panel (Table  1 ). Table 1 Minimum referral information dataset for MRD Referral item Mandatory Patient demographics and contact information (name, surname, sex, date of birth, and contact details) ✓ Referring physician identity and contact ✓ Specific diagnostic question ✓ Parity (obstetric history) ✓ Prior pelvic surgery ✓ Fecal incontinence ✓ Urinary incontinence ✓ Obstructed defecation ✓ Obstructed voiding ✓ Chronic pelvic pain ✓ Pelvic organ prolapses (if possible, by compartment) ✓\nMinimum referral information dataset for MRD\nThe final referral template mandates the inclusion of key demographic, clinical, and functional history elements considered essential to guide MRD protocol selection and ensure accurate and clinically meaningful interpretation.\nBased on a narrative literature review and feedback collected during the initial panel meeting, 36 candidate statements were generated. These statements were evaluated over three rounds of anonymous voting, with iterative revisions guided by qualitative feedback. Remote plenary sessions were subsequently held to discuss borderline items and promote convergence.\nOverall, consensus was achieved for 21 out of 36 statements (58.3%), while 15 statements (41.7%) were rejected (Table  2 ). Table 2 Delphi consensus summary Delphi item category Total statements (n=36) Accepted (%) (n=21, 58%) Rejected (%) (n=15, 42%) Technical (radiologists only) 11 11 (100) 0 (0) Anatomical/functional (all panelists) 25 10 (40.0) 15 (60.0)\nDelphi consensus summary\nThe accepted statements (Table  3 ) included both technical parameters (11/11; 100%) and anatomical/functional parameters (10/25; 40%). Collectively, these items defined a core dataset intended to improve interobserver reproducibility, reporting completeness, and clinical applicability across institutions. Technical consensus items focused on standardizing acquisition and measurement details, including reporting of magnet characteristics, patient preparation and positioning, contrast administration, imaging phases, and key quantitative measurements such as the anorectal angle and pelvic reference lines. Anatomical and functional consensus items addressed the systematic evaluation of PFD across compartments, functional abnormalities, and the inclusion of a structured final impression aligned with the clinical referral question. Table 3 Statement-derived items to enter a structured MRD report Category Item Agreement (%) Technical Magnet type (open/closed) 84.6 Field strength 92.3 Bowel preparation and type 76.9 Patient position during defecation phase 77.0 Acquisition of static/dynamic phases 100 Type and amount of contrast agent 76.9 Contrast administration site(s) (rectum, vagina, bladder, bowel) 76.9 Imaging planes acquired 76.9 Anorectal angle measured at rest, squeeze, strain, evacuation 84.6 H-line, M-line, O-line relative to pubococcygeal line 76.9 Any contrast leakage during filling phase 100 Anatomical/functional Puborectalis dyssynergia 85.0 Prolapse(s) in the anterior/middle/posterior compartments 95.0 Rectocele 95.0 Intussusception (recto-rectal/recto-anal) 95.0 Enterocele / sigmoidocele 95.0 Rectal inertia (Impaired rectal evacuation) 95.0 Urethro-vesical angle modifications 100 Structural visceral/muscular alterations (e.g., levator avulsion) 100 Structured final impression addressing the clinical question 85.0 Suggestion for any further diagnostic work-up 80.0\nTechnical consensus items focused on standardizing acquisition and measurement details, including reporting of magnet characteristics, patient preparation and positioning, contrast administration, imaging phases, and key quantitative measurements such as the anorectal angle and pelvic reference lines.\nAnatomical and functional consensus items addressed the systematic evaluation of PFD across compartments, functional abnormalities, and the inclusion of a structured final impression aligned with the clinical referral question.\nStatement-derived items to enter a structured MRD report\nThe 15 rejected statements (Table  4 ) predominantly concerned items considered technically burdensome, insufficiently standardized in the literature, or beyond the radiologist’s diagnostic remit. These included additional pelvic floor measurements (e.g., levator hiatus dimensions), post-evacuation imaging protocols, reporting of hardware specifications, bibliographic referencing of measurement systems, and radiologist-driven therapeutic recommendations. Table 4 Statements not accepted after Delphi rounds Statement Agreement (%) Report magnet position (i.e., horizontal or vertical) 69.2 Include post-evacuation images after toilet use 69.2 Report diameters/area of levator hiatus 69.3 Measure rectal diameters at maximum filling and post-evacuation 69.3 Describe number/type of expulsive acts 69.2 Report site and quantity of residual contrast 69.3 Specify the coil type (body vs. phased array) 46.2 Report the sequence (whether static or dynamic was acquired first) 53.9 Timing of the static phase acquisition relative to contrast administration 46.2 Include bibliographic footnotes for measurement systems and anatomical landmarks 61.6 Report diameters of the anal canal at rest and during evacuation 53.9 Include the levator plate angle and infrapubic horizontal line 61.6 Report the percentage/fraction of contrast expelled 61.6 Radiologist should suggest a medical treatment 20.0 Radiologist should suggest a surgical treatment 20.0\nStatements not accepted after Delphi rounds\nAlthough several statements approached the predefined consensus threshold (e.g., levator hiatus measurements, 69.3%), they were excluded to maintain feasibility, reduce reporting complexity, and limit interobserver variability.\nAt the conclusion of the Delphi process, the panel unanimously endorsed both standardized tools. A representative example of the final consensus-derived structured MR defecography report is provided below to facilitate understanding and practical implementation of the proposed framework (Table  5 ). Table 5 Structured MRD Reporting Template Section Item Details/fields Patient and referral information Patient demographics and contact information Name, surname, sex, date of birth, contact details Referring physician Name and contact information Clinical history Parity Obstetric history Prior pelvic surgery Yes / No (specify) Symptoms Fecal incontinence (Yes / No) Urinary incontinence (Yes / No) Obstructed defecation (Yes / No) Obstructed voiding (Yes / No) Chronic pelvic pain (Yes / No) Pelvic organs prolapse Known or suspected prolapse (specify compartment) Technical parameters Magnet type Open / Closed Field strength ___ Tesla Bowel preparation Yes / No (specify type) Patient position during defecation phase Supine / Sitting / Other (specify) Static phases acquired Yes / No (specify planes) Dynamic phases acquired Yes / No (Rest / Squeeze / Strain / Evacuation) Contrast agent type ___ Contrast agent amount ___ mL Contrast administration sites Rectum / Vagina / Bladder / Bowel Imaging planes acquired Sagittal / Axial / Coronal Anorectal angle Rest: ___°; Squeeze: ___°; Strain: ___°; Evacuation: ___° H-line ___ mm M-line ___ mm O-line ___ mm Contrast leakage during filling phase Yes / No Anatomical and functional findings Compartmental prolapse None / Present (Anterior, Middle, Posterior compartment) Puborectalis dyssynergia Absent / Present Rectocele Absent / Present (specify size) Intussusception Absent / Present (Recto-rectal / Recto-anal) Enterocele / Sigmoidocele Absent / Present Rectal inertia Absent / Present Urethro-vesical angle modifications Absent / Present Levator avulsion / muscular alterations Absent / Present Structured final impression Summary of findings Key findings relevant to the clinical question Compartment(s) involved ___ Functional alterations ___\nStructured MRD Reporting Template\nFecal incontinence (Yes / No)\nUrinary incontinence (Yes / No)\nObstructed defecation (Yes / No)\nObstructed voiding (Yes / No)\nChronic pelvic pain (Yes / No)\n\nThis Delphi consensus represents the first multidisciplinary initiative in Italy aimed to standardize both the referral process and the reporting of MRD in patients with PFD. The two tools developed are designed to improve communication between referring physicians and radiologists, reduce interobserver variability, and promote a shared language across specialties [ 17 ].\nA key strength of this initiative lies in its multispecialty integration. PFD are inherently complex, often involving more than one anatomical compartment, and their optimal management requires the coordinated input of colorectal surgeons, gynecologists, urologists, radiologists, gastroenterologists, and physiatrists. The consensus process confirmed that radiological reporting cannot be conceived in isolation but must be tailored to the specific needs of referring clinicians. The explicit rejection of radiologist-driven therapeutic recommendations (20% agreement) underscores the importance of preserving professional boundaries while fostering a constructive diagnostic–clinical dialog.\nFrom a technical and practical perspective, the structured template emphasizes feasibility and reproducibility. Accepted items prioritized parameters widely recognized in the literature and feasible in routine practice, such as the anorectal angle, H/M/O lines, and prolapse grading across compartments [ 12 ]. Conversely, technically demanding or poorly standardized parameters (e.g., levator hiatus diameters, post-evacuation measurements) did not reach consensus. This pragmatic balance ensures that the proposed dataset can be consistently applied across centers without introducing excessive variability or extending reporting time beyond what is sustainable in daily clinical activity.\nThe adoption of structured reporting for MRD confers multiple methodological, clinical, and research-related advantages. By enforcing standardized terminology, predefined reporting fields, and systematic documentation of both technical and interpretative parameters, structured MRD reporting improves report completeness, internal consistency, and clarity. This structured approach may reduce interpretative ambiguity and interobserver variability, which are well-recognized limitations of narrative reporting, particularly in complex functional imaging examinations [ 15 ,  18 ].\nImportantly, the value of structured reporting extends beyond reporting standardization. The systematic collection of quantitative measurements, functional parameters, and clinically relevant descriptors generates high-quality, interoperable datasets that can facilitate multicenter research, quality assurance initiatives, and longitudinal outcome studies. Moreover, the adoption of standardized reporting frameworks represents a prerequisite for the development of advanced data-driven approaches, including radiomics and artificial intelligence applications, by enabling reproducible extraction and comparison of imaging-derived information across institutions. In this context, structured MRD reporting may contribute to the future identification of imaging biomarkers and support the development of more objective and reproducible assessment strategies for pelvic floor disorders.\nFrom a clinical perspective, structured reporting facilitates more effective communication among radiologists, surgeons, gastroenterologists, and pelvic floor specialists by ensuring that imaging findings are explicitly linked to the clinical indications and diagnostic questions that prompted the examination. This alignment enhances the clinical relevance of MRD reports and supports more informed multidisciplinary decision-making, with potential downstream benefits for patient management and treatment planning [ 19 ].\nBeyond individual patient care, standardized MRD reporting establishes a reproducible and harmonized framework for data collection across institutions. This uniformity is essential for multicenter clinical research, enabling reliable aggregation and comparison of imaging data, reducing heterogeneity in outcome measures, and improving the robustness of observational studies and clinical trials. Structured reports also provide a consistent basis for quality assurance, auditing, and performance benchmarking, supporting continuous improvement in imaging practice [ 14 ].\nNonetheless, some limitations must be acknowledged: structured templates may reduce flexibility, potentially omitting rare or atypical findings not included in the dataset. For instance, the assessment of megarectum—often defined by transverse rectal diameter in the mid rectum—was not retained in our consensus, despite previous work highlighting its potential clinical relevance [ 20 ]. The exclusion of borderline items, while necessary for feasibility, may risk overlooking emerging but not yet validated parameters; and the successful implementation of structured reporting requires dedicated training and a cultural shift among radiologists and clinicians alike.\nComparable initiatives have been undertaken in other fields of imaging. For example, structured MR reporting templates have been developed for anal fistula [ 11 ], endometriosis [ 15 ], multiple sclerosis [ 21 ], and malignant diseases [ 22 – 24 ], with evidence suggesting improvements in report quality, reproducibility, and clinical usability.\nIn the field of PFD, international efforts have been undertaken to standardize reporting across different modalities. For example, Paquette et al. [ 8 ] described a consensus-based structured template for fluoroscopic (barium) defecography, while Gurland et al. [ 7 ] proposed standardized terminology and interpretative criteria for MRD with multispecialty endorsement. More recently, Piloni et al. [ 25 ] developed an Italian structured reporting format for MRD including nine descriptors, based on literature review and expert opinion. While these initiatives represent important contributions, the former primarily addressed fluoroscopic imaging, the second focused on MRD terminology and interpretation without a formal reporting dataset, and the latter was mainly radiology-driven without a consensus methodology. In addition, Revels et al. [ 9 ] synthesized these consensus efforts and provided practical reporting templates and lexicon recommendations, mainly emphasizing objective measurements and compartment-based assessment. Our Delphi process expands on these initiatives by systematically integrating multiple specialties and by producing two complementary tools (a referral dataset and a reporting template) formally endorsed through consensus.\nBuilding on these results, the next step will be a prospective, multicenter validation of the proposed templates. Each participating unit will implement the structured format in routine practice, generating data on usability, clarity, and interpretability from both radiologists and referring clinicians. This pilot phase will allow iterative refinement of the tools and establish a platform for outcome-based studies evaluating the real-world impact of structured MRD reporting on diagnostic accuracy, multidisciplinary decision-making, and patient outcomes.\nThis study is inherently limited by its consensus-based design and the absence of prospective validation, reproducibility analyses, and interobserver agreement assessment. Consequently, the impact of the proposed templates on reporting standardization, diagnostic performance, and clinical decision-making remains to be established. Although the panel was composed exclusively of Italian experts, participants were selected through a purposive sampling strategy based on recognized expertise in pelvic floor disorders and MR defecography. The multidisciplinary panel included highly experienced specialists from high-volume referral centers, providing a robust foundation for the consensus process. Nevertheless, international validation is warranted to confirm the generalizability of the recommendations across different healthcare settings. Finally, implementation feasibility, including workflow integration, reporting time, and user acceptance, was not evaluated and should be addressed in future multicenter studies.\nIn conclusion, this modified Delphi consensus study established a multidisciplinary framework for standardized MR defecography referral and reporting, integrating a structured clinical referral dataset with a comprehensive reporting template. By involving experts from multiple specialties dedicated to the management of pelvic floor disorders, the study identified a core set of clinically relevant parameters considered essential for the consistent acquisition, interpretation, and communication of MR defecography findings. The proposed framework provides a practical reference for reporting standardization and multidisciplinary communication and may contribute to greater uniformity in MR defecography practice across institutions. Furthermore, it offers a foundation for future research initiatives, educational activities, and the development of shared reporting standards in pelvic floor imaging. Future studies should focus on validating the proposed framework and assessing its reproducibility and applicability in broader clinical settings.","source_license":"CC-BY-4.0","license_restricted":false}